Basic Information
| Provider Information | |||||||||
| NPI: | 1811660343 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELAM | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | BS, RBT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 S DOUGLAS RD STE 230 | ||||||||
| Address2: | |||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331344108 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1630 BRAEBURN DR | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | VA | ||||||||
| PostalCode: | 241537371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5405889582 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2021 | ||||||||
| LastUpdateDate: | 07/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
ID Information
| ID | Type | State | Issuer | Description | 350993044033 | 05 | VA | MEDICAID |